Concealed Handgun Carry License Lost Or Destroyed License Replacement Request Form printable pdf download

ARKANSAS STATE POLICE

Concealed Handgun Carry License

Lost or Destroyed License Replacement Request Form

PLEASE TYPE OR PRINT LEGIBLY

Name: ___________________________________________________________________________________________

LAST

FIRST

MIDDLE

Arkansas Concealed Handgun Carry License #: _____________________________________ Exp date: _____________

(if known)

Physical address: ___________________________________________________________________________________

(STREET)

_____________________________________ , ___________________________, AR __________________________

(CITY)

(COUNTY)

(ZIP CODE)

Mailing address:____________________________________________________________________________________

(P. O. BOX #, ETC.)

___________________________________, ______________________________, AR __________________________

(CITY)

(COUNTY)

(ZIP CODE)

Date of Birth:________________ Race: _____ Sex: _______ Cell Phone number:_____________________________

Daytime telephone number:(_____)_____________________ E-mail address:__________________________________

Arkansas driver’s license number: ____________________________________ Expiration date: ____________________

NOTICE: Knowingly providing false information on this form is against Arkansas law Ark. Code Ann §5-73-305. The

applicant, by completing this form, swears or affirms that he/she is in compliance with and meets all the qualifications to

hold a license to carry a concealed handgun pursuant to the criteria specified in Ark Code Ann §5-73-308 and §5-73-309

and any other state and federal law.

I hereby state under oath that the representations made herein are true and correct.

Signature of Applicant: ________________________________________

Date:________________________

(

First/MI/Last Name)

(Month/Day/Year)

This form MUST be notarized before submittal to the Arkansas State Police.

State of Arkansas

County of

Subscribed and sworn before me a notary public in and for the county aforesaid this _________ day of

_____________, 20___.

Notary Public Signature:_____________________________________ My commission expires:

YOU MUST ENCLOSE THE FOLLOWING WITH THIS REQUEST:

1. This properly completed form.

2. A legible copy of your Arkansas Concealed Handgun Carry License (if possible).

3. A legible copy of your Arkansas Driver’s License or I.D. Card.

4. a. If you are 64 years of age or younger - A check or money order for $15.00 payable to the Arkansas State Police.

b. If you are 65 years of age or older – A check or money order for $7.50 payable to the Arkansas State Police

Mail your request packet to: Arkansas State Police, CHCL Section, 1 State Police Plaza Drive,

Little Rock, AR 72209

Effective January 1, 2009

Revised April 2013

Concealed Handgun Carry License Lost Or Destroyed License Replacement Request Form

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